CT-Guided Celiac Ganglion Block for Neurogenic Gastrointestinal Dysmotility.

PURPOSE: To determine whether celiac ganglion block can serve as a diagnostic test for dysautonomia as the cause of gastrointestinal dysmotility-related symptoms. MATERIALS AND METHODS: This was an institutional review board-approved, prospective, single-arm, registered study, from January 2020 to May 2021, and included patients aged 14-85 years with gastrointestinal symptoms of food intolerance, abdominal pain, or angina. Patients with nonneurogenic causes (ie, chronic cholecystitis, peptic ulcer disease, gastroesophageal reflux, and malabsorption syndrome) were excluded. All 15 patients underwent computed tomography-guided celiac ganglion block with 100 mg of liposomal bupivacaine. Patients filled out the dysautonomia-validated questionnaire Composite Autonomic Symptom Score 31 (COMPASS-31) before and after intervention. Differences (before vs after) were compared with the exact permutation method. RESULTS: Fifteen women (median age, 17 years; range, 14-41 years) were included. Average COMPASS-31 score improved significantly, from baseline 11 (SD ± 2.8) to 4 (SD ± 1.9) (improvement, 7 points ± 2.8; P < .001). All patients reported significant reduction in abdominal angina. Fourteen of the 15 patients (93%) reported complete resolution, and 14 of 15 (93%) reported a significant reduction in non-postprandial abdominal pain (P < .01). Only 1 patient reported no improvement. Eight of those 14 patients (57%) reported complete resolution of abdominal pain. There was a significant improvement in functional scores (vomiting, P = .01; constipation frequency, P = .02; constipation severity, P < .01; and nausea, P < .01). The rate of minor and major adverse events was 13% and 0%, respectively, per the Society of Interventional Radiology adverse event classification. CONCLUSIONS: Celiac ganglion block is a safe diagnostic tool for confirming dysautonomia as the underlying condition in patients with gastrointestinal dysmotility-related symptoms. It could provide early diagnosis, lead to definitive treatment (ganglionectomy) earlier, or obviate unnecessary surgery.

Percutaneous Cryoablation for Stage 1 Renal Cell Carcinoma: Outcomes from a 10-year Prospective Study and Comparison with Matched Cohorts from the National Cancer Database.

Background Percutaneous cryoablation (PCA) is an increasingly utilized treatment for stage I renal cell carcinoma (RCC), albeit without supportive level I evidence. Purpose Primary objective was to determine the 10-year oncologic outcomes of PCA for stage I RCC in a prospective manner. Secondary objectives were to compare outcomes after partial nephrectomy (PN) and radical nephrectomy (RN) from the National Cancer Database (NCDB), to determine long-term renal function, and to determine the risk of metachronous disease. Materials and Methods In this institutional review board-approved prospective observational study (2006-2013), study participants with single, sporadic, biopsy-proven RCC were included to calculate the 10-year overall survival, recurrence-free survival, and disease-specific survival after PCA. Results were compared with matched PN and RN NCDB cohorts. Overall and recurrence-free survival probabilities were estimated by using nonparametric maximum likelihood estimator. Disease-specific survival was estimated by using the redistribution-to-right method. Age at diagnosis was stratified as a risk for survival. The effect on estimated glomerular filtration rate, serum creatinine level, and the risk for hemodialysis and metachronous disease were calculated. Results One hundred thirty-four patients (46% men) with single, sporadic, biopsy-proven RCC (median size ± standard deviation, 2.8 cm ± 1.4) were included. Overall survival was 86% (95% confidence interval [CI]: 80%, 93%) and 72% (95% CI: 62%, 83%), recurrence-free survival was 85% (95% CI: 79%, 91%) and 69% (95% CI: 59%, 79%) (improved over surgery), and disease-specific survival was 94% (95% CI: 90%, 98%) at both 5 years and 10 years (similar to surgery), respectively. The 10-year risk of hemodialysis was 2.3%. Risk of metachronous RCC was 6%. Charlson/Deyo Combined Comorbidity score analysis showed decreasing overall survival with increasing comorbidity index. The PCA cohort outperformed both RN- and PN-matched subgroups in all Charlson/Deyo Combined Comorbidity score categories. Conclusion Percutaneous cryoablation yielded a 10-year disease-specific survival of 94%, equivalent to that reported after radical or partial nephrectomy. Overall survival probability after percutaneous cryoablation at 5 years and 10 years was longer than for radical or partial nephrectomy, especially for patients at higher risk (Charlson/Deyo Combined Comorbidity score ≥2). © RSNA, 2020.

Spontaneous breast hematoma as a complication of anticoagulation therapy requiring angiography and embolization.

Spontaneous breast hematoma is a rare complication of therapeutic anticoagulation therapy with few cases reported in the literature. We present a case of spontaneous breast hematoma resulting in hypotension and symptomatic anemia. Angiography demonstrated multiple sites of hemorrhage within the breast, which was treated with gelatin sponge embolization. This case highlights the role of interventional radiology in the treatment of breast hematoma, as well as reviews the arterial vascular anatomy of the breast.

Complications of renal cryoablation: a single center experience.

PURPOSE: We describe perioperative complications associated with renal cryoablation and identify potential risk factors for certain complications. MATERIALS AND METHODS: We retrospectively analyzed the medical records of patients with unifocal renal masses treated with cryosurgery at a single center between 1997 and 2007. All complications associated with these procedures were documented and classified into grades 1 to 5 by the Clavien surgical complication classification. In-depth analysis was done to identify potential risk factors for the most common complications. RESULTS: We evaluated 101 percutaneous, 52 laparoscopic and 9 open procedures. Complications were noted in 38 procedures (23.5%), including grades 1 to 4 in 19 (11.7%), 8 (4.9%), 5 (3.1%) and 6 (3.7%), respectively, as the severest complication. The most common complication was flank pain (11 procedures), followed by perinephric hematoma and cardiovascular complications (10 each). Mass size (p = 0.001), number of cryoablation probes (p <0.001) and chronic anticoagulation (p <0.05) were associated with an increased incidence of significant hematoma. Cardiovascular complications were more common when upper pole lesions were treated, and when an open approach was used (each p <0.05). Respiratory complications occurred in 7 procedures and were associated with patient age (p <0.05) and mass size (p <0.01). CONCLUSIONS: Cryoablation is a relatively safe procedure with a low complications rate in properly selected patients. We identified potential risk factors that may help identify patients most at risk for certain complications and consequently assist in preprocedural planning and counseling.

Salvage therapy for liver-dominant colorectal metastatic adenocarcinoma: comparison between transcatheter arterial chemoembolization versus yttrium-90 radioembolization.

PURPOSE: To compare transarterial chemoembolization (CE) versus yttrium-90 ((90)Y) radioembolization (RE) for liver-dominant metastatic colorectal adenocarcinoma as salvage therapy. MATERIALS AND METHODS: Of 36 patients, 21 underwent CE (37 procedures; 11 men; mean age, 67 years; 16 with Child-Pugh class A disease) and 15 underwent (90)Y RE (19 procedures; 11 men; mean age, 64 years; 13 with Child-Pugh class A disease) for liver-dominant colorectal adenocarcinoma. Mean index dominant lesion sizes were 9.3 cm and 8.2 cm in the CE and RE groups, respectively. Multilobar disease was seen in 67% and 87% of the respective groups, and extrahepatic metastases were seen in 43% and 33%, respectively. Mean times from diagnosis of liver metastasis to CE or RE were 17.6 months and 22.6 months, respectively. RESULTS: A total of 37 CE procedures with cisplatin, doxorubicin, and mitomycin were performed, and 19 RE procedures with (90)Y were performed; 43% of patients in the CE group and 20% in the RE group received multiple treatment sessions, and 100% of procedures were technically successful. Median survival times were 7.7 months for the CE group and 6.9 months for the RE group (P = .27). The 1-, 2-, and 5-year survival rates were 43%, 10%, and 0%, respectively, in the CE group; and 34%, 18%, and 0%, respectively, in the RE group. There was one major complication (2.7%) in the CE group (pulmonary embolism), with a 30-day mortality rate of 5.4% (n = 2). There were no major complications in the RE group, with a 30-day mortality rate of 5.2% (n = 1). CONCLUSIONS: Patients with unresectable liver colorectal metastases that progress despite systemic chemotherapy can undergo palliative treatment with CE or RE with similar survival benefit.

Adrenal vein sampling with and without cosyntropin stimulation for detection of surgically remediable aldosteronism.

CONTEXT AND OBJECTIVE: Bilateral adrenal vein sampling (AVS), the diagnostic standard for identifying surgically remediable aldosteronism (SRA), is commonly performed after cosyntropin stimulation (post-ACTHstim). The role of AVS without cosyntropin stimulation (pre-ACTHstim) has not been established. The selectivity index (SI), the adrenal vein (av) serum cortisol concentration divided by that in a peripheral vein, confirms av sampling. The minimally acceptable SI is controversial. The objectives of this study were to determine the role of pre-ACTHstim AVS and a predetermined SI. DESIGN: Using biochemical cure as the endpoint, we performed a retrospective head-to-head comparison of pre-ACTHstim AVS to post-ACTHstim AVS. The specificity of a predetermined minimum SI of 1.5 in pre-ACTHstim AVS was determined. PATIENTS: At a regional AVS referral centre, we analysed 32 patients who had undergone simultaneous bilateral AVS both pre- and post-ACTHstim and had returned for postadrenalectomy evaluation. MEASUREMENTS: Simultaneous bilateral AVS was performed with measurements of venous concentrations of aldosterone and cortisol. End points were postadrenalectomy plasma renin activity, serum aldosterone concentration, and number of antihypertensive medications. RESULTS: All 32 patients achieved a biochemical cure following adrenalectomy. The two AVS protocols were complementary. Notably, seven patients (22%; CI = 11-38) were found to have SRA by a lateralization index (LI) > 4 on the pre-ACTHstim AVS, but not on the post-ACTHstim AVS. SI pre-ACTHstim was divided into tertiles. Specificity was 100% in all. CONCLUSIONS: Simultaneous bilateral AVS performed both pre-ACTHstim and post-ACTHstim maximizes SRA identification. A SI of 1.5 pre-ACTHstim does not reduce specificity.

Nonresectable hepatocellular carcinoma: long-term toxicity in patients treated with transarterial chemoembolization--single-center experience.

PURPOSE: To determine the toxicity profile of transarterial chemoembolization (TACE) at 6 months and 1 year after treatment in patients with hepatocellular carcinoma (HCC) in a standardized oncology protocol so that TACE could be compared with systemic chemotherapeutic regimens for liver cancer. MATERIALS AND METHODS: The study was authorized by the institutional review board. Between January 2002 and January 2007, 190 patients (155 men, 35 women; median age, 65 years; age range, 18-84 years) with HCC who underwent TACE treatment were identified from a prospectively collected database. Clinical records of complete blood cell counts and chemical profiles at baseline and at 6 and 12 months after treatment were studied retrospectively. Toxicity was graded according to the common terminology criteria for adverse events (CTCAE). A transition (survival) analysis perspective was used to estimate the distribution of toxicity grades. Patient survival from the first TACE session was calculated with Kaplan-Meier analysis. RESULTS: Grade 3 or 4 toxicity 6 and 12 months, respectively, after treatment included leukocytopenia (7% and 19%); anemia (9% and 19%); thromobocytopenia (13% and 23%); prolonged activated partial thromboplastin time (8% and 18%); elevated aspartate aminotransferase (15% and 18%), alanine aminotransferase (10% and 18%), and alkaline phosphatase (8% and 18%) levels; hypoalbuminemia (10% and 19%); hyperbilirubinemia (10% and 22%); and alopecia (18%). The cumulative survival rate was 58% at 1 year, 39% at 2 years, and 29% at 3 years. These toxicity rates were considerably lower than those reported after treatment with currently used systemic chemotherapeutic agents. CONCLUSION: Study results show that TACE has a favorable long-term toxicity profile in patients with HCC. Data clearly support the role of TACE in the treatment of patients with nonresectable HCC.

Safety and efficacy of CT-guided percutaneous cryoablation for renal cell carcinoma.

PURPOSE: Image-guided percutaneous cryoablation is a treatment alternative for selected patients with renal cell carcinoma (RCC). The objective of the present study was to present the safety and efficacy of percutaneous cryoablation. MATERIALS AND METHODS: The study included 51 lesions in 46 consecutive patients treated with computed tomography (CT)-guided percutaneous cryoablation. Results were based on 40 RCCs with follow-up. Patients had baseline history and physical and laboratory examinations and renal CT or magnetic resonance (MR) imaging and were followed every 3 months. Biopsy of all lesions was performed before or at the time of the procedure. Efficacy was defined as a complete lack of enhancement on follow-up contrast agent-enhanced CT or MR imaging. Lesion size was also followed and correlated with lack of enhancement. Short- and long-term complications were tabulated. RESULTS: The technical success rate was 100%, with 20% of cases requiring some form of thermal protection of an adjacent organ. During follow-up (median, 28 weeks; range, 4-81 weeks), the efficacy rate was 100% for lesions smaller than 7 cm. The incidence of significant complications was 18% (8% CTAE), mostly (10%) intercostal or genitofemoral nerve injury. All patients with complications recovered fully, and there were no mortalities. There was no change in creatinine levels, and no patient developed renal failure as a result of cryoablation. CONCLUSIONS: CT-guided percutaneous cryoablation resulted in complete response for lesions as large as 4 cm. It may also be a viable alternative for nonsurgical candidates with lesions as large as 7 cm. It has a high efficacy rate, and its modest complications are not only comparable to those of other treatment modalities, but also appear to be reversible.

Chemoembolization of hepatic metastases from ocular melanoma: assessment of response with contrast-enhanced and diffusion-weighted MRI.

OBJECTIVE: The purpose of this study was to assess the utility of assessment of tumor size and enhancement with diffusion-weighted and conventional MRI in the evaluation of response to transarterial chemoembolization therapy for metastatic ocular melanoma. CONCLUSION: In patients with ocular melanoma and liver metastasis treated with transarterial chemoembolization, functional MRI showed significant changes in the lesions. These changes included a decrease in tumor enhancement and an increase in the apparent diffusion coefficient of the tumor, suggesting increasing tumor necrosis and cell death.

Functional MRI evaluation of tumor response in patients with neuroendocrine hepatic metastasis treated with transcatheter arterial chemoembolization.

OBJECTIVE: The purpose of this study was to evaluate contrast-enhanced and diffusion-weighted MRI changes in neuroendocrine tumors treated with transcatheter arterial chemoembolization (TACE). MATERIALS AND METHODS: Sixty-six targeted lesions in 26 patients (18 men, eight women; mean age, 57 years) with hepatic metastasis of neuroendocrine tumors treated with TACE were retrospectively analyzed. MRI studies were performed before and after TACE. Imaging features included tumor size, percentage of enhancement in the arterial and portal venous phases, and diffusion-weighted imaging apparent diffusion coefficients (ADCs) of the tumor, liver, and spleen. Tumor response to treatment was recorded according to World Health Organization criteria and Response Evaluation Criteria in Solid Tumors. Liver function tests were performed, and clinical performance was assessed before and after treatment. Statistical analysis included paired Student's t tests and Kaplan-Meier survival curves. RESULTS: Mean tumor size and percentage enhancement in the arterial and portal venous phases decreased significantly after treatment (p < 0.0001). The tumor ADC increased from 1.51 x 10(-3) mm2/s before treatment to 1.79 x 10(-3) mm2/s after treatment (p < 0.0001), but the ADCs for the liver and spleen remained unchanged. Despite the change in tumor size, no patient in this cohort achieved complete response according to World Health Organization criteria and Response Evaluation Criteria in Solid Tumors. Partial response was achieved in only 27% and 23% of the patients according to the respective criteria. Results of liver function tests and performance status also remained unchanged. The mean survival period for all patients was 78 months. CONCLUSION: Contrast-enhanced and diffusion-weighted imaging showed significant changes after TACE of neuroendocrine tumors and can be used to assess response of targeted tumors.

CT-Guided, Percutaneous Ethanol Sympatholysis for Primary Hyperhidrosis.

PURPOSE: Primary hyperhidrosis (PH) typically involves the craniofacial (CF) or axillary-palmar (AP) region. Our purpose was to determine the safety and efficacy of CT-guided sympatholysis for treating PH. METHODS: In this prospective study, 39 consecutive patients with CF or AP PH were referred for percutaneous sympatholysis. Procedures were performed under CT guidance and minimal sedation. We treated level T2 for CF hyperhidrosis and T2, T3, and T4 for AP hyperhidrosis. Twenty-two-gauge spinal needles were placed bilaterally at the anterolateral surface of the vertebral body. After infiltration of lidocaine (2 mL), a neurological test was performed to exclude Horner syndrome. Neurolysis was effected with ethanol (2 mL) via each needle. Patients were discharged 1 h postoperatively and followed up at 1 week, 1 month, and then as clinically indicated. Disease-free Kaplan-Meier curves were compared using log-rank tests. Complications were categorized according to Common Terminology Criteria for Adverse Events. RESULTS: One patient failed the lidocaine test and was excluded. Of the 38 patients included in this cohort (16 men), mean age was 38 years (range 18-61), and mean follow-up was 18 months (range 1-36). Technical success for these 38 patients was 100%. Seventeen patients had symptom recurrence, 14 of whom were retreated. Efficacy was 72% for CF hyperhidrosis, 50% for AP hyperhidrosis, and 60% overall. There were three major complications (two pneumothoraces, one severe intercostal neuralgia requiring medication). CONCLUSIONS: CT-guided sympatholysis for CF or AP PH had 18-month efficacy rates of 72 and 50%, with a favorable risk profile. LEVEL OF EVIDENCE: Level 2b.

Single 15-Min Protocol Yields the Same Cryoablation Size and Margin as the Conventional 10-8-10-Min Protocol: Results of Kidney and Liver Swine Experiment.

INTRODUCTION: The objective was to determine the ablation size of a single 15-min freeze and compare it with the conventional 10-min freeze-8-min thaw-10-min freeze protocol. Secondary objectives were to determine the ablation margin and to ascertain whether islands of viable tissue remain within the ablation zone. MATERIALS AND METHODS: Five adult swine under general anesthesia were used. After surgical abdominal exposure, two ablations were performed in liver and two in kidney. One ablation utilized the 15-min and the second the 10-8-10-min protocol. At maximum ice-ball, tissue ink was infused via an angiographic catheter in hepatic or renal artery to stain the non-frozen tissue. Animals were euthanized and organs examined macro- and microscopically. RESULTS: Three histological regions were observed: (A) a viable/stained region representing the tissue outside the ice-ball, (B) a central necrotic area representing the ablated region within the ice-ball and (C) an unstained but viable margin representing the non-lethal margin within ice-ball. Ablation size did not vary with protocol but did for tissue type. Renal ablation was approximately 5 × 4 cm with both protocols, whereas liver ablation was approximately 6.7 × 4.4 cm. Ablation margin was measured at 1 mm irrespective of ablation protocol or tissue. No islands of viable tissue were identified within the ablation zone. DISCUSSION: Fifteen-minute cryoablation yielded an ablation size and margin identical to that of the conventional 10-8-10-min protocol. Within the ablated region, cell death was uniform. The only difference was a larger cryoablation zone in hepatic tissue compared to renal tissue, likely attributable to differences in blood perfusion.

Targeted transarterial therapy of Vx-2 rabbit liver tumor with Yttrium-90 labeled ferromagnetic particles using an external magnetic field.

BACKGROUND: Our goal was to study the efficacy of liver cancer embolization with magnetically targeted Yttrium-90 labeled ferromagnetic particles and establish the biodistribution profile of these particles. MATERIALS AND METHODS: Of twenty rabbits, nine underwent transarterial radioembolization of implanted Vx-2 tumor with increasing 90Y-MTC doses, three were treated with carrier particles alone, four remained untreated and four were sacrificed early to document biodistribution. At various intervals, animals were sacrificed and biodistribution, liver cancer viability and toxicity were measured. RESULTS: There was a dose related degree of tumor necrosis, with greater than 90 Gy yielding 100% necrosis (baseline 50%). Blood radioactivity one hour post-radioembolization was less than 0.0275 microCi/g. No hematological toxicity was observed. Except for the non-targeted right liver lobe, organ radioactivity levels were within tolerance levels. Significant left (targeted) hepatic lobe necrosis was seen in subjects receiving high doses. CONCLUSION: Hepatic arterial radioembolization with 9Y-MTC bolstered by external magnetic field has significant tumoricidal effect and a favorable biodistribution profile.

Resolution of generalized compensatory hyperhidrosis related to sympathectomy, after T2 sympatholysis.

Compensatory hyperhidrosis (CH) is common after sympathectomy, and most treatments are ineffective. We present a 36-year-old man whose CH was effectively treated with percutaneous sympatholysis. The patient's axillary-palmar hyperhidrosis had been treated with T3-4 sympathetic ligation. The patient developed CH involving the head, face, back, torso and feet and was referred for computed tomography-guided percutaneous T2 sympatholysis for craniofacial symptoms, after which the patient experienced resolution of CH (complete face/neck/feet and partial back/torso), despite the treated level being above the previous ligation.

Pre- and postoperative clinical care of patients undergoing interventional oncology procedures: a comprehensive approach to preventing and mitigating complications.

Interventional radiology (IR) is transforming itself into a fully fledged clinical specialty. Successful practices will have to adapt to this environment by developing the requisite clinical skills and acquiring the associated privileges. To thrive, an IR physician will have to develop strong clinical skills, be intimately familiar with the relevant disease, IR procedure, its possible complications and how to address them effectively. From an administrative point of view, successful practices will have to follow a multidisciplinary approach to treatment that involves other physician-specialists and develop a diverse IR group that can provide appropriate pre- and post-intervention clinical care. The above are especially necessary in order to offer interventions such as arterial embolizations and percutaneous ablations which are rapidly becoming the mainstay of treatment for non-surgical patients (and increasingly surgical patients as well) with cancer.

Incorporating physician assistants and physician extenders in the contemporary interventional oncology practice.

Interventional radiology (IR) has been for the last few years undergoing a transformation from a service oriented to a clinically oriented specialty. With increasing oncologic procedures and patient volume, the balance between quality clinical care, and the time constraints on the busy interventionalist pull in opposing forces. The need for greater clinical support staff in the IR practice is unquestionable. Physician Assistants (and other Physician Extenders) have been in the medical field since the 1960s with intensive clinical training, capabilities of providing patient care and ability to generate revenue income more than justifies their place in the IR. The contemporary model of a clinical orientated service within IR for cancer patients undergoing interventional oncology procedures should include Physician Extenders as a vital part of the team allowing delivery of high-quality patient care.

Kidney Cancer.

The number of new cases of renal cell carcinoma has been steadily increasing since the 1960s, reaching 62,000 and 89,000 annually in the United States and Europe, respectively, in 2016. The current standard of care for early-stage disease is nephron-sparing surgery, which has a demonstrated long-term disease-free survival and an acceptable safety profile. Technical developments (thin, powerful probes and real-time image guidance systems) have allowed image-guided percutaneous ablation to become a viable option for stage I renal cell carcinoma. Because of the widespread use of cross-sectional imaging, most renal tumors (75%) are indeed detected incidentally at stage I (75%). As a result, ablation is a potentially curable intervention and one that could mitigate surgical risks. All 3 ablative modalities (radiofrequency ablation, microwave ablation, and cryoablation) have been extensively applied. The utilization of ablation was initially hampered by the lack of prospective, long-term oncologic data. As a result, ablation was reserved for specific subgroups of patients, for example, patients with solitary kidney, chronic kidney disease, or bilateral disease; poor surgical candidates; or patients with syndromes that predispose them to renal cell cancer. Recently, however, studies on percutaneous ablation for early-stage renal cancer have yielded prospective, long-term oncologic data, affirming the earlier, lower-level-evidence studies. The reported efficacy of ablation for stage I renal cancer (especially cryoablation) appears to rival that of the accepted standard of care (nephron-sparing surgery), whereas its safety profile is a decided advantage. In conclusion, image-guided percutaneous ablation should be considered a viable, curative option for stage IA renal cell carcinoma.